JCIPatientSafety.orgHospital Quality Directory

Acute Care Hospitals · Voluntary non-profit - Private

Kaiser Foundation Hospital and Rehab Center

2 / 5

At a glance

Kaiser Foundation Hospital and Rehab Center carries a 2-star CMS overall rating — below the national norm. On healthcare-associated infection measures, it performs better than the national average on 12 and worse on 0.

Healthcare-Associated Infections

lower is better · 36 measures reported

Rates of infections patients can acquire while receiving care, such as central-line and catheter-associated infections, MRSA, and C. difficile.

MeasureScoreCompared to national
Central Line Associated Bloodstream Infection (ICU + select Wards): Lower Confidence Limit0.375Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Upper Confidence Limit2.267Same as national
Central Line Associated Bloodstream Infection: Number of Device Days4814Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Predicted Cases4.888Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards): Observed Cases5Same as national
Central Line Associated Bloodstream Infection (ICU + select Wards)1.023Same as national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Lower Confidence LimitBetter than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Upper Confidence Limit0.603Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Number of Urinary Catheter Days4069Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Predicted Cases4.968Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards): Observed Cases0Better than national
Catheter Associated Urinary Tract Infections (ICU + select Wards)0.000Better than national
SSI - Colon Surgery: Lower Confidence Limit0.852Same as national
SSI - Colon Surgery: Upper Confidence Limit3.853Same as national
SSI - Colon Surgery: Number of Procedures137Same as national
SSI - Colon Surgery: Predicted Cases3.594Same as national
SSI - Colon Surgery: Observed Cases7Same as national
SSI - Colon Surgery1.948Same as national
SSI - Abdominal Hysterectomy: Lower Confidence LimitNot available
SSI - Abdominal Hysterectomy: Upper Confidence LimitNot available
SSI - Abdominal Hysterectomy: Number of Procedures15Not available
SSI - Abdominal Hysterectomy: Predicted Cases0.134Not available
SSI - Abdominal Hysterectomy: Observed Cases1Not available
SSI - Abdominal HysterectomyNot available
MRSA Bacteremia: Lower Confidence Limit0.019Same as national
MRSA Bacteremia: Upper Confidence Limit1.921Same as national
MRSA Bacteremia: Patient Days46578Same as national
MRSA Bacteremia: Predicted Cases2.568Same as national
MRSA Bacteremia: Observed Cases1Same as national
MRSA Bacteremia0.389Same as national
Clostridium Difficile (C.Diff): Lower Confidence Limit0.251Better than national
Clostridium Difficile (C.Diff): Upper Confidence Limit0.751Better than national
Clostridium Difficile (C.Diff): Patient Days44020Better than national
Clostridium Difficile (C.Diff): Predicted Cases28.863Better than national
Clostridium Difficile (C.Diff): Observed Cases13Better than national
Clostridium Difficile (C.Diff)0.450Better than national

Complications & Deaths

lower is better · 20 measures reported

Rates of serious complications (like hip/knee replacement problems or accidental cuts during surgery) and 30-day mortality rates for common conditions.

MeasureScoreCompared to nationalSample
Rate of complications for hip/knee replacement patientsNot available
Hybrid Hospital-Wide All-Cause Risk Standardized Mortality Rate4.3Same as national188
Death rate for heart attack patientsNot available
Death rate for CABG surgery patientsNot available
Death rate for COPD patientsNot available
Death rate for heart failure patients14.9Same as national29
Death rate for pneumonia patients19.1Same as national30
Death rate for stroke patientsNot available
Pressure ulcer rate0.41Same as national842
Death rate among surgical inpatients with serious treatable complicationsNot available
Iatrogenic pneumothorax rate0.20Same as national941
In-hospital fall-associated fracture rate0.26Same as national954
Postoperative hemorrhage or hematoma rate2.22Same as national163
Postoperative acute kidney injury requiring dialysis rateNot available
Postoperative respiratory failure rate8.91Same as national26
Perioperative pulmonary embolism or deep vein thrombosis rate4.20Same as national167
Postoperative sepsis rateNot available
Postoperative wound dehiscence rate1.75Same as national39
Abdominopelvic accidental puncture or laceration rate1.00Same as national176
CMS Medicare PSI 90: Patient safety and adverse events composite0.97Same as national

Unplanned Hospital Visits & Readmissions

lower is better · 14 measures reported

How often patients return to the hospital unexpectedly within 30 days of discharge — a marker of care quality and discharge planning.

MeasureScoreCompared to nationalSample
Hospital return days for heart attack patientsNot available
Hospital return days for heart failure patientsNot available
Hospital return days for pneumonia patients18.4Not available26
Hybrid Hospital-Wide All-Cause Readmission Measure (HWR)14.6Same as national260
Rate of unplanned hospital visits after colonoscopy (per 1,000 colonoscopies)Not available
Rate of inpatient admissions for patients receiving outpatient chemotherapyNot available
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapyNot available
Ratio of unplanned hospital visits after hospital outpatient surgeryNot available
Acute Myocardial Infarction (AMI) 30-Day Readmission RateNot available
Rate of readmission for CABGNot available
Rate of readmission for chronic obstructive pulmonary disease (COPD) patientsNot available
Heart failure (HF) 30-Day Readmission RateNot available
Rate of readmission after hip/knee replacementNot available
Pneumonia (PN) 30-Day Readmission Rate15.9Same as national26

Patient Experience (HCAHPS)

higher is better · 9 measures reported

What patients say about their hospital stay — communication with nurses and doctors, responsiveness, cleanliness, pain management, and whether they would recommend the hospital.

MeasureScoreSample
Nurse communication - star rating31056
Doctor communication - star rating41056
Communication about medicines - star rating31056
Discharge information - star rating41056
Cleanliness - star rating31056
Quietness - star rating31056
Overall hospital rating - star rating41056
Recommend hospital - star rating41056
Summary star rating41056

Timely & Effective Care

higher is better (unless a wait time) · 30 measures reported

How consistently hospitals follow recommended care processes — for example, giving heart-attack patients aspirin on arrival, or the average time spent in the emergency department.

MeasureScoreSample
Emergency department volume
Global Malnutrition Composite Score
Global Malnutrition Composite Score: Malnutrition Diagnosis Documented
Global Malnutrition Composite Score: Malnutrition Risk Screening
Global Malnutrition Composite Score: Nutrition Assessment
Global Malnutrition Composite Score: Nutritional Care Plan
Hospital Harm - Severe Hyperglycemia712534
Hospital Harm - Severe Hypoglycemia22369
Hospital Harm - Opioid Related Adverse Events
Healthcare workers given influenza vaccination465142
Average (median) time all patients spent in the emergency department before leaving from the visit, including psychiatric/mental health patients and patients who were transferred to another facility. A lower number of minutes is better
Average (median) time patients spent in the emergency department before leaving from the visit, excluding patients transferred to another facility or psychiatric care/mental health patients. A lower number of minutes is better
Average (median) time psychiatric/mental health patients spent in the emergency department before leaving from the visit. A lower number of minutes is better
Average (median) time patients spent in the emergency department before being transferred to another facility. A lower number of minutes is better
Left before being seen
Head CT results
Endoscopy/polyp surveillance: appropriate follow-up interval for normal colonoscopy in average risk patients
Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery
ST-Segment Elevation Myocardial Infarction (STEMI)
Safe Use of Opioids - Concurrent Prescribing81622
Appropriate care for severe sepsis and septic shock70158
Septic Shock 3-Hour Bundle7356
Septic Shock 6-Hour Bundle8131
Severe Sepsis 3-Hour Bundle90158
Severe Sepsis 6-Hour Bundle94108
Discharged on Antithrombotic Therapy9199
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Antithrombotic Therapy by End of Hospital Day 2
Venous Thromboembolism Prophylaxis
Intensive Care Unit Venous Thromboembolism Prophylaxis

Maternal Health

lower is better · 4 measures reported

Measures of maternal outcomes and safe delivery practices, including severe complications during childbirth.

MeasureScoreSample
Cesarean Birth
Risk Adjusted Severe Obstetric Complications (All)
Risk Adjusted Severe Obstetric Complications (excluding blood-transfusion-only cases)
Maternal Morbidity Structural MeasureYes

Frequently asked questions

How is Kaiser Foundation Hospital and Rehab Center rated?
Kaiser Foundation Hospital and Rehab Center has a 2 out of 5 CMS overall star rating as of the latest CMS release.
Does Kaiser Foundation Hospital and Rehab Center have emergency services?
According to CMS records, Kaiser Foundation Hospital and Rehab Center does not report a 24/7 emergency department.
Where is Kaiser Foundation Hospital and Rehab Center located?
Kaiser Foundation Hospital and Rehab Center is located at 975 Sereno Dr, Vallejo, CA 94589.
What type of hospital is Kaiser Foundation Hospital and Rehab Center?
Kaiser Foundation Hospital and Rehab Center is classified by CMS as a Acute Care Hospitals facility (Voluntary non-profit - Private).

Data as of 2026-06-14. Source: CMS Provider Data Catalog. This is public data provided for informational purposes only and is not medical advice. See our methodology and editorial policy.

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